H1N1 Clinicians Questions and Answers

October 2, 2009, 3:30 PM ET

Who is recommended to receive the 2009 H1N1 flu vaccine?
When vaccine is first available, the CDC Advisory Committee on Immunization Practices (ACIP) has recommended the 2009 H1N1 vaccine for the following 5 target groups (approximately 159 million persons nationally):

Pregnant women
Household and caregiver contacts of children younger than 6 months of age (e.g. parents, siblings, and daycare providers)
Health care and emergency medical services personnel
Persons from 6 months through 24 years of age
Persons aged 25 through 64 years who have medical conditions associated with a higher risk of influenza complications

Once providers meet the demand for vaccine among persons in these initial target groups, vaccination is recommended for all persons 25 through 64 years of age. Current studies indicate that the risk for infection among persons age 65 or older is less than the risk for younger age groups. However, once vaccine demand among younger age groups has been met, programs and providers should offer vaccination to people 65 or older.

How should providers prioritize among the initial target groups recommended by ACIP?
The recommendations are broad and allow for flexibility to accommodate local variability in vaccine needs and demands. Providers should be aware of and follow any additional guidance provided by their state or local health departments. If no additional guidance is provided at the state or local level, providers should vaccinate among the initial target group populations on a first come, first served basis.

How likely is it that recommendations for target groups may change during the immunization period?
Although it is unlikely the ACIP recommendations will change, predicting the behavior of 2009 H1N1 influenza virus is difficult. CDC will continue to monitor the epidemiology of the evolving pandemic very closely. The Advisory Committee on Immunization Practices will be updated frequently on the status of the pandemic, including groups at highest risk of complications, and recommendations will be modified as necessary.

How will the 2009 H1N1 vaccine flow from manufacturers to providers?
The Federal Government will allocate vaccine to states based on population size. States are responsible for identifying providers who will participate in administration of 2009 H1N1 vaccine. Vaccine will be shipped to participating providers through a centralized distribution process. Through this process, placing of orders is facilitated by the state/local health department, and this information sent to CDC to be transferred to the distributor for processing. Because of limitations related to the number of sites to which the distributor can directly ship vaccine, some project areas (includes all states, territories, Chicago, DC, NYC, and LA county) may develop additional means of distributing vaccine to providers which will be communicated to providers on a local level.

How can providers obtain vaccine?
State/Local public heath departments will be responsible for directing the flow of vaccine to providers within every state. They will determine which providers will receive vaccine, and will allocate vaccine among providers as it becomes available to them. Public health departments are in the process of ascertaining which providers are interested in administering vaccine. For more information go to your state’s public health department website or to the CDC 2009 H1N1 website for information on how to become a 2009 H1N1 vaccine provider. Participating providers will sign a Provider Agreement assuring they intend to meet state requirements

Will vaccine be distributed equitably across providers?
Public health departments will strive to ensure equitable distribution, taking into account which target groups are seen by different types of providers as well as their internal resources for possible re-distribution of vaccine.

What supplies will be included with the 2009 H1N1 vaccine shipments?
The Federal Government will purchase vaccine and supplies (syringes, alcohol swabs, sharps containers, and vaccine record cards) and distribute these at no cost to healthcare providers who make agreements with state and local public health authorities to provide the 2009 H1N1 vaccine. Supplies will be shipped separately from vaccine and are expected to arrive before or on the same day as vaccine.

How can providers determine what percentage of their patients plan on getting the 2009 H1N1 vaccine in a physician’s office?
It is difficult to predict where individuals will go to receive the 2009 H1N1 vaccine. However, based on unpublished data from the Adult National Immunization Survey, during the 2006-2007 influenza season, among 19-49 year olds who were vaccinated, approximately 38% of persons at increased risk of complications from influenza reported receiving influenza vaccine in a physician’s office. Approximately 26% of persons with household contact with a high risk person and 25% of persons with no specific indications for influenza vaccine were vaccinated in a physician’s office.

What are some possible approaches a practice might take to administer the 2009 H1N1 vaccine?
Options include holding special clinics, integrating the 2009 H1N1 vaccination into usual care, providing walk-in immunizations, or coordinating with local public health clinics if unable to administer 2009 H1N1 vaccine themselves. In determining the best option, each practice should consider several factors, including availability of vaccine, practice resources and patient demand.

If my patients are vaccinated outside of my practice, how will that information be available for inclusion in the patient’s permanent medical record?
Recipients of the 2009 H1N1 vaccine will be provided with a hand-held card to serve as a record of vaccination and a source of information should a report to the Vaccine Adverse Event Reporting System (VAERS) be needed. Vaccine recipients will be encouraged to bring the hand-held card at their next visit to their primary care provider so that vaccination information can be transcribed into the patient’s permanent medical record.

What CDC information will be available for use in practices to help explain the need for both seasonal and 2009 H1N1 vaccine?
A variety of materials are available on the CDC 2009 H1N1 website at http://www.cdc.gov/h1n1flu/vaccination/. In addition, a 2009 H1N1-specific Vaccine Information Statement (VIS) will be available that will help explain the vaccine to recipients.

Can patients who are allergic to eggs receive the 2009 H1N1 flu vaccine?
Asking persons if they can eat eggs without adverse effects is a reasonable way to determine who might be at risk for allergic reactions from receiving influenza vaccines. Persons who have had symptoms such as hives or swelling of the lips or tongue, or who have experienced acute respiratory distress after eating eggs, should consult a physician for appropriate evaluation to help determine if influenza vaccine should be administered. Persons who have documented (IgE)-mediated hypersensitivity to eggs, including those who have had occupational asthma related to egg exposure or other allergic responses to egg protein, also might be at increased risk for allergic reactions to influenza vaccine, and consultation with a physician before vaccination should be considered. A regimen has been developed for administering influenza vaccine to asthmatic children with severe disease and egg hypersensitivity (J Pediatr 1985;106:931-3.).

Will private health insurance plans reimburse private providers for administration of 2009 H1N1 vaccine?
According to America’s Health Insurance Plans, a national association representing nearly 1,300 companies that provide health insurance to over 200 million Americans, “Every year health plans contribute to the seasonal flu vaccination campaign in several ways:
a) Health plans communicate directly with plan sponsors and members on the current ACIP recommendations and encourage immunization; they also provide information on where to get vaccinations, and who to contact with any questions.
b) Just as health plans have provided extensive coverage for the administration of seasonal flu vaccines in the past, public health planners can make the assumption that health plans will provide reimbursement for the administration of 2009 H1N1 vaccine to their members by private sector providers in both traditional settings e.g., doctor’s office, ambulatory clinics, health care facilities, and in non-traditional settings, where contracts with insurers have been established.”

Can seasonal influenza vaccine and 2009 H1N1 vaccine be given at the same visit?
Both seasonal and 2009 H1N1 vaccines are available as inactivated and live attenuated (LAIV) formulations. The simultaneous and sequential administration of seasonal and 2009 H1N1 inactivated vaccines is currently being studied. However, existing recommendations are that two inactivated vaccines can be administered at any time before, after, or at the same visit as each other (General Recommendations on Immunization, MMWR 2006;55[RR-15]). Existing recommendations also state that an inactivated and live vaccine may be administered at any time before, after or at the same visit as each other. Consequently, providers can administer seasonal and 2009 H1N1 inactivated vaccines, seasonal inactivated vaccine and 2009 H1N1 LAIV, or seasonal LAIV and inactivated 2009 H1N1 at the same visit, or at any time before or after each other. Live attenuated seasonal and live 2009 H1N1 vaccines should NOT be administered at the same visit until further studies are done. If a person is eligible and prefers the LAIV formulation of seasonal and 2009 H1N1 vaccine, these vaccines should be separated by a minimum of four weeks.

Can 2009 H1N1 vaccine be administered at the same visit as other vaccines?
Inactivated 2009 H1N1 vaccine can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine. Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine.

Will the 2009 H1N1 vaccine be recommended for patients who had influenza-like illness since spring 2009?
All people in a recommended vaccination target group who did not have 2009 H1N1 virus infection confirmed by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) test should be vaccinated with the 2009 H1N1 vaccine. People who had an illness confirmed by rRT-PCR to be 2009 H1N1 virus earlier in 2009 can be considered to be immune and do not need to be vaccinated this year. However, most people with respiratory illnesses since this spring have not had testing with the rRT-PCR test, which is the only test that can confirm infection specifically with the 2009 H1N1 virus. Tests such as rapid antigen detection assays and diagnoses based on symptoms alone without rRT-PCR testing, cannot specifically determine if a person has 2009 H1N1 influenza. Although people who were not tested, but who became ill within 1-4 days after close contact with a person with lab confirmed 2009 H1N1 influenza might have been infected with 2009 H1N1, they cannot be certain since many pathogens can cause respiratory illness. These people should get the 2009 H1N1 vaccine as recommended for their age and risk group.

People who were infected with the 2009 H1N1 virus and who are not severely immune compromised will likely have immunity to subsequent infection with 2009 H1N1 virus. However, vaccination of a person with some existing immunity to the 2009 H1N1 virus will not be harmful, and patients who are uncertain about how they were diagnosed should get the 2009 H1N1 vaccine. In addition, people recommended for seasonal vaccine should get a seasonal vaccine because infection with the 2009 H1N1 virus does not provide protection against seasonal influenza viruses.

The age for two doses is different for seasonal (6 months through 8 years) and 2009 H1N1 monovalent vaccine (6 months through 9 years) in the package inserts. Does CDC recommend that clinicians follow the recommendation in the package inserts?
CDC recommends that clinicians follow the guidance in the manufacturer package inserts. For 2009 H1N1 monovalent vaccines, that means that clinicians should administer two doses of 2009 H1N1 monovalent vaccine to children 6 months through 9 years of age. Persons 10 years and older should receive one dose.

The interval between 2009 H1N1 monovalent vaccine doses, for children 6 months through 9 years, is stated as "approximately 1 month" in the package inserts. What does "approximately 1 month" mean?
CDC recommends that the two doses of 2009 H1N1 monovalent vaccine be separated by 4 weeks. However, if the second dose is separated from the first dose by at least 21 days the second dose can be considered to be valid. If the interval separating the doses is less than 21 days the second dose should be repeated four weeks after the first dose was given.

If seasonal live attenuated influenza vaccine (LAIV) and 2009 H1N1 LAIV are given during the same visit, do either or both doses need to be repeated, and if so, when?
There are no data on the administration of seasonal and 2009 H1N1 LAIV during the same visit. CDC's Advisory Committee on Immunization Practices (ACIP) recommends that seasonal and 2009 H1N1 LAIV not be administered during the same visit. However, if both types of LAIV are inadvertently administered during the same visit, neither vaccine needs to be repeated.

If seasonal and 2009 H1N1 LAIV are not administered during the same visit, but are separated by less than 4 weeks, do either or both doses need to be repeated, and if so, when?
Seasonal LAIV and 2009 H1N1 LAIV should not be administered during the same visit, and should be separated by at least 4 weeks. However, if the interval between administration of LAIV and seasonal 2009 H1N1 vaccine is less than 4 weeks, neither vaccine needs to be repeated.

Can a person who has received LAIV test positive on a rapid influenza diagnostic test?
The live attenuated influenza vaccine viruses in LAIV (seasonal vaccine and 2009 H1N1 monvalent vaccine) can cause a positive result on a rapid influenza diagnostic test. The tests are designed to detect influenza viruses and cannot differentiate between live attenuated and wild-type influenza viruses. A positive test in a person who recently (in the previous 7 days) received LAIV and who also has an influenza-like illness could be caused by either LAIV or wild-type influenza virus.

FROM THE CENTER FOR DISEASE CONTROL:

Swine Influenza and You

What is swine flu?
Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and do happen. Swine flu viruses have been reported to spread from person-to-person, but in the past, this transmission was limited and not sustained beyond three people.

Are there human infections with swine flu in the U.S.?
In late March and early April 2009, cases of human infection with swine influenza A (H1N1) viruses were first reported in Southern California and near San Antonio, Texas. Other U.S. states have reported cases of swine flu infection in humans and cases have been reported internationally as well. An updated case count of confirmed swine flu infections in the United States is kept at http://www.cdc.gov/swineflu/investigation.htm CDC and local and state health agencies are working together to investigate this situation.

Is this swine flu virus contagious?
CDC has determined that this swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it is not known how easily the virus spreads between people.

What are the signs and symptoms of swine flu in people?
The symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.

How does swine flu spread?
Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

How can someone with the flu infect someone else?
Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or more days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

What should I do to keep from getting the flu?
First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.

Are there medicines to treat swine flu?
Yes. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with these swine influenza viruses. Antiviral drugs are prescription medicines (pills, liquid or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms).

How long can an infected person spread swine flu to others?
People with swine influenza virus infection should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children, especially younger children, might potentially be contagious for longer periods.

What surfaces are most likely to be sources of contamination?
Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk and then touches their own eyes, mouth or nose before washing their hands.

How long can viruses live outside the body?
We know that some viruses and bacteria can live 2 hours or longer on surfaces like cafeteria tables, doorknobs, and desks. Frequent handwashing will help you reduce the chance of getting contamination from these common surfaces.

What can I do to protect myself from getting sick?
There is no vaccine available right now to protect against swine flu. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these everyday steps to protect your health:

Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
Avoid touching your eyes, nose or mouth. Germs spread this way.
Try to avoid close contact with sick people.
If you get sick with influenza, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

What is the best way to keep from spreading the virus through coughing or sneezing?

If you are sick, limit your contact with other people as much as possible. Do not go to work or school if ill. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Put your used tissue in the waste basket. Cover your cough or sneeze if you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze.

What is the best technique for washing my hands to avoid getting the flu?
Washing your hands often will help protect you from germs. Wash with soap and water. or clean with alcohol-based hand cleaner. we recommend that when you wash your hands -- with soap and warm water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel does not need water to work; the alcohol in it kills the germs on your hands.

What should I do if I get sick?
If you live in areas where swine influenza cases have been identified and become ill with influenza-like symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea, you may want to contact their health care provider, particularly if you are worried about your symptoms. Your health care provider will determine whether influenza testing or treatment is needed.

If you are sick, you should stay home and avoid contact with other people as much as possible to keep from spreading your illness to others.

If you become ill and experience any of the following warning signs, seek emergency medical care.

In children emergency warning signs that need urgent medical attention include:

Fast breathing or trouble breathing
Bluish skin color
Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse cough
Fever with a rash

In adults, emergency warning signs that need urgent medical attention include:

Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting

How serious is swine flu infection?
Like seasonal flu, swine flu in humans can vary in severity from mild to severe. Between 2005 until January 2009, 12 human cases of swine flu were detected in the U.S. with no deaths occurring. However, swine flu infection can be serious. In September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu and died 8 days later. A swine flu outbreak in Fort Dix, New Jersey occurred in 1976 that caused more than 200 cases with serious illness in several people and one death.

Can I get swine influenza from eating or preparing pork?
No. Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork products is safe.